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Aortic dissection
Aortic dissection
Aortic dissection
Aortic dissection
Aortic dissection
Aortic dissection
Aortic dissection
Aortic dissection
Aortic dissection
Aortic dissection
Aortic dissection
Aortic dissection
Aortic dissection
Aortic dissection
Aortic dissection
Aortic dissection
Aortic dissection
Aortic dissection
Aortic dissection
Aortic dissection
Aortic dissection
Aortic dissection
Aortic dissection
Aortic dissection
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Aortic dissection

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Case presentation and brief review aortic dissection

Case presentation and brief review aortic dissection

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  • 1. Aortic dissection
  • 2. Case presentation50 yo man BIBA at 0230 with 3 hours of dull non-radiating central chest pain.En route, administered O2, 300mg Aspirin, 10mg Morphine and 10mg MetoclopramidePain free on arrival.
  • 3. Previously wellNo positive risk factors for IHD or PENo regular medication or other drug useNo trauma or recent infections
  • 4. No prior episodes of chest painVomited twice at home, and described as clammy and pale on arrival of ambulance, with BP 90/60 supine.
  • 5. On arrivalPaleTemp 37 HR 60BP 60/40mmHg RR 14O2 sat 100% (3L/min)GCS 15/15Equal radial pulses4/6 Systolic murmurLungs clear to auscultation
  • 6. ECG
  • 7. Initial treatmentIV fluid 1L Normal saline statColour improved, BP to 90/60 mmHg,Pain freeEarly investigations:Trop T < 3 ng/L (N < 15)
  • 8. CXR
  • 9. Course2nd ECG normal and Trop T < 3 at 6 hours post onset of pain2nd litre of saline running, BP still 90/60mm/Hg, HR 60/min, with normal peripheral perfusionBP both arms the sameChest pain “2/10”Decision to order CT angiogram of chest
  • 10. Intimal tear / flap ofdissection in aortic arch
  • 11. 7.10AM Patient transferred to the OT for repair of the type A dissection and the aneurysmal dilatation of aortic root.
  • 12. Aortic Dissection
  • 13. Relatively uncommon (2.6-3.3/100 000 person- years)Initial event in aortic dissection is a tear in the aortic intima.Propagation of the dissection may be 1. Proximal (retrograde) 2. Distal (antegrade)
  • 14. Complications Aortic valve injury with regurgitation Pericaridal tamponade End organ ischemia, examples include syncope, CVA, mesenteric or renal ischaemia.
  • 15. Risk factors for aortic dissectionAdvancing ageMale sex 2:1 (Female – pregnancy)Systemic hypertensionPre-existing aortic aneurysmAtherosclerosis
  • 16. Risk factors for under age 40Collagen vascular disordersVasculitisBicuspid aortic valveAortic coarctationTurners syndromeMarfan syndromePrior aortic valve surgeryInstrumentationTraumaHigh intensity weight lifting or other exerciseCocaine
  • 17. ClassificationStanfordType A –ascending AortaType B – all other types / sites in aortaDeBakeyType I – Originates in ascending aorta, propagates at least to the aortic arch and often beyond it distally.Type II – Originates / confined to the ascending aorta.Type III – Originates in descending aorta, rarely extends proximally but will extend distally.
  • 18. DiagnosisRoutine bloods – non diagnostic D-dimer < 500ng/ml unlikely to be dissectionHistory Anterior chest pain in ascending aortic dissection Severe sharp or tearing posterior chest or back pain when the dissection progresses distal to the subclavian artery
  • 19. Pain can associated withSyncopeStrokeMIHeart failureEnd organ ischemia (splanchnic, renal, extremity or spinal cord ischaemia)Hypertension common with type BHypotension
  • 20. Diagnosis of aortic dissection dependsupon demonstration of the dissection onimaging studies CXR CT MRI TEE / TTE
  • 21.  CT
  • 22. Immediate managementMaintain airway, good supportive careTreat hypotension / hypertension – aim for MAP 60-70 Beta blockers eg esmalol propranolol, labetalol Vasodilators Na nitroprusside Calcium channel blockers eg verapamil, diltiazem
  • 23. ManagementType A – SurgicalType B – Surgical/medical

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